By submitting this form, you are affirmatively acknowledging and agreeing to the terms and conditions outlined below. You are certifying that the information provided is accurate and truthful to the best of your knowledge. You are granting permission to Comprehensive Spine & Sports Center, MI (hereinafter referred to as 'clinic' and 'the clinic') and its associated health professionals to collect, use, and disclose your personal and medical information as necessary for your treatment and as described in this form. You are also acknowledging your understanding and acceptance of our cancellation, financial, and payment policies.
You are voluntarily consenting to the rendering of care, including treatment and diagnostic procedures, and you understand that you are under the care and supervision of the attending physician(s). You are acknowledging receipt and understanding of the HIPAA Privacy Notice and your rights and responsibilities as a patient.
By submitting this form, you are also affirmatively stating that you understand and agree to the non-discrimination policy of the clinic and that you consent to the release of information as outlined in this form.
Please read the following sections carefully and ask any questions you may have before submitting this form.
Accuracy of Information
I certify that the above medical information is correct to my knowledge.
Privacy and Sharing of Information
I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.
Cancellation Policy
Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the doctor's day that could have been filled by another patient. As such, we require 5 hours notice for any cancellations or changes to your appointment. Thank you so much for your help!
Financial Policy
Thank you for choosing our facility. We are committed to providing you with quality health care. Your clear understanding of our Patient Financial Policy is important to our professional relationship. Please understand that payment for services is part of that relationship. Please ask if you have any questions about our fees, policies, or your responsibilities. It is your responsibility to notify our office if any information changes (i.e., name, address, telephone number, insurance information, etc.)
Insurance. We participate with most insurance plans, including Medicare. If you are not insured by a plan we are contracted with, payment in full is expected at each visit. If you are insured by a plan we are contracted with but do not have an up-to-date insurance card, payment in full for each visit is required if we cannot verify your coverage. While we are happy to help you understand your benefits as they pertain to our office, knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage. It is also your responsibility to know if we are in-network with your specific health plan. Our insurance verification MAY take a couple of days, and you will be expected to pay for those services rendered if your insurance is out of network, including Medicare and Medicaid plans. Payment plans and options are available upon request.
Co-payments, Deductibles, and Coinsurance. All co-payments, deductibles and coinsurance must be paid at the time of services. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments, deductibles, and coinsurance from patients can be considered fraud. Please help us in upholding the law by paying your patient responsibility at each visit. To make payments convenient, we accept all major credit cards, cash and checks. We reserve the right to use the credit card on file to pay all outstanding balances.
Self-Pay Accounts are for patients without insurance coverage. This also includes patients covered by insurance plans in which the office does not participate with, or patients without an insurance card on file. Patients may also opt to be self-pay regardless of their insurance coverage. It is always the patient's responsibility to know if our office participates with their plan. If there is a discrepancy with our information, the patient will be considered self-pay unless otherwise proven. Payment plans are available upon request. It is never our intention to cause hardship to our patients, only to provide the best care possible with the least amount of stress.
Proof of Insurance. All patients must complete an intake form before seeing the doctor. We must obtain a copy of your driver's license and valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, based on your insurance policies, you may be responsible for the balance of a claim. If your insurance changes, please notify us ASAP before your next visit so we can make sure the appropriate changes are made to help you receive your maximum benefits.
Claims Submission. We will submit your claims and assist you in any way we can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefits is a contract between you and your insurance company; we are not party to that contract.
Minors. The parent(s) or guardian(s) is responsible for full payment and will receive the billing statements.
Referrals/Authorizations. Some insurance policies require referrals and/or authorizations. It is your responsibility to be aware of this. Our office will inform and assist in retrieving these items, but the ultimate responsibility is yours. We will let you know everything you need to obtain for these if your plan happens to require one. Any services rendered without a referral or authorization where one was required will result in the patient being billed for the service.
Regardless of any personal arrangements that a patient might have outside of our office, if you are over 18 years of age and receiving treatment, you are ultimately responsible for payment of the service. Our office will not bill any other personal party. Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area. Thank you for understanding our financial policy. Please let us know if you have any questions or concerns.
Informed Consent
To the patient (or their parent, legal guardian, court appointed conservator, or agent): Please read this entire form prior to signing it. It is important that you understand the information contained in this form. Please ask any questions prior to signing this form if you are unclear about anything in this form.
Chiropractic Manipulation or Adjustments: The primary treatment rendered by the Chiropractic Physician to you will be chiropractic manipulation or adjustments, which are purposely intentioned movements of bones with the desired effect being to remove interferences to nerves, which then allows your body to use its innate ability to heal itself. Chiropractic adjustments also have the desirable effect of enabling muscles, tendons, and ligaments to properly function and heal, and also allow blood flow to properly occur. Chiropractic adjustments can be made by either the use of hands or mechanical instruments to any bone or joint in the body including both spinal and extremity bones. You may or may not hear an audible sound, which is just air being released from the joint space as bones are moved into their proper positions.
Other Procedures: There are a number of other procedures used by Chiropractic Physicians that may be used on you. A physical examination will be performed to obtain a baseline level of functioning as well as to partially determine an appropriate course of treatment and associated recommendations. The physical examination may include posture checks, range of motion testing, muscle strength testing, various neurological and orthopedic testing, and other testing. Radiology may be ordered if necessary. Treatment may include chiropractic adjustments, physical therapy (such as ultrasound, interferential therapies, massage therapy, exercise recommendations, etc.). Additionally, there may be referrals to other doctors as necessary, and their treatment should involve the same informed consent with disclosure of risks and benefits as is being done here. For example, there can be permanent pain as a side effect of surgery as one possible consequence of that procedure.
Potential Benefits of Chiropractic and Associated Care: The vast majority of chiropractic patients tend to achieve good to excellent improvement in their physical conditions with chiropractic care. Improvement can be measured in many different ways, including reduction in pain, increased range of motion, less stiffness, increased athletic performance, and other ways. It must be remembered that different people get different results; different people have pre-existing conditions, and are of different ages and occupations (with different types of physical stress). Your situation is unique, and no guarantees are given. You will have to determine what results you get for yourself and report them to your Chiropractic Physician.
Material Risks Inherent with Chiropractic Adjustments and Other Treatment: As with any healthcare procedure, there are certain complications which may arise when chiropractic adjustments and other care/procedures are performed. These complications include but are not limited to fractures of bones, disc injuries, dislocations, muscle strains, cervical myelopathy, strokes, radiation exposure, costovertebral strains and separations, and burns. Some patients feel some stiffness and/or soreness following the first few days of treatment. The physical exam can temporarily worsen symptoms, but is a necessary part of chiropractic care. The Doctor of Chiropractic will make every reasonable effort during the examination to screen for contraindications to care, but remember it is your responsibility to inform the Doctor of Chiropractic of any conditions that would not otherwise come to their attention.
Probability of Risks Occurring: Fractures are rare occurrences and generally result from some underlying weakness of bone. Even though a competent history, examination (which may include radiography) will be performed, it is still possible for some weakness of bone to be undetected. Extremely rare are strokes from vertebral artery dissection which also occur in about one person in 133,000 in general (not related to chiropractic), but are estimated to occur in between one in one million and one in five million cervical adjustments. Although discs are generally helped with chiropractic care, they can be worsened even to the point of requiring surgical care (although this rarely occurs). Physical therapy can sometimes burn skin by irritating it, although this is unlikely to occur.
A perspective on the risks of chiropractic care as compared to medical care can be seen by the money paid by different doctors for a $1,000,000 malpractice liability policy. The following annual premiums listed are close approximations, although not exact. A general medical doctor pays about $20,000 per year, an internal medicine specialist pays about $50,000 per year, and a medical specialist such as surgeons, cardiologists, and obstetrics and gynecologists (OBGYN) pay about $150,000 per year for a $1,000,000 malpractice liability policy. In stark contrast to medical doctors whose patients encounter significantly more risk than Doctors of Chiropractic, Doctors of Chiropractic in California pay about $1,600 per year. Also, it has been reported that about 187,000 deaths occur every year from medical malpractice, but that the number for chiropractic is typically zero per year.
Consequences of Not Obtaining Chiropractic Care: Not obtaining chiropractic care will have the effect of not obtaining its benefits such as having your body function at its best ability, reducing pain, peak athletic performance, etc. Not obtaining chiropractic care may allow formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult, requiring more time (and money), and less effective when chiropractic care is obtained later in time. Not obtaining chiropractic care following trauma such as whiplash or other effects of automobile accidents will cause injured muscles, tendons, and ligaments to heal improperly and be significantly weaker and more prone to re-injury as compared to receiving proper chiropractic care.
Alternatives to Chiropractic Care: Other treatment options for your condition may include rest, acupuncture, physical therapy, medical care, medications (both over the counter and prescribed), hospitalizations, surgery, and others. If you choose to use other treatment options, you should discuss the risks and benefits with your medical doctor or other health care provider.
HIPAA Acknowledgement
I acknowledge that I have received and had an opportunity to read the HIPPA Privacy Notice, and I understand the ways in which my health information may be used and disclosed as well as my rights with respect to this information.
Non-Discrimination Statement
This clinic does not exclude, deny benefits to, or otherwise discriminate against any person on the ground of race, color, national origin, disability, age, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected genetic information in admission to, participation in, or receipt of the services and benefits under any of its programs and activities.
Patient Rights and Responsibilities
As a patient, you have the right to receive quality care, to privacy, to confidentiality, and to access your medical records. You also have the responsibility to provide accurate and complete information, to follow the treatment plan, to pay for your care, to ask questions when you do not understand, and to be respectful to healthcare personnel.
Patient Consent Form
Consent for Treatment: I voluntarily consent to the rendering of care, including treatment and performance of diagnostic procedures. I understand that I am under the care and supervision of the attending physician and it is the responsibility of the staff to carry out the Instructions of such physician(s).
Release of Information: The physician(s) may disclose all or part of the patient's record to any person or corporation which is or may be liable under contract to the physician(s) or to the patient or to a family member or employer of the patient for all part of part of the physician's charges, including, but not limited to; insurance companies, worker's compensation carriers, welfare funds, or the patient's employer.
H.M.O. Disclaimer: I certify that I am not presently enrolled In any Health Maintenance Organization (HMO) Subsequent rejection of a claim as a result of this admission, due to current enrollment in an H.M.O. plan will constitute responsibility for payment of claim on my part.
Medicare and Medicaid Patient Certification-Patient's Certification Authorization to Release Information and Payment Request:
I certify that the Information given by me in applying for payment under Title XVIII and/or Title XI of the Social Security Act, is correct. I authorize any holder of medical or other information about me, to release to the Social Security Administration or its intermediary carriers, any information needed for this or related Medicare or Medicaid claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician(s) services. I understand that I am responsible for my health insurance deductibles and coinsurance.